<!DOCTYPE html>
<html xmlns:th="http://www.thymeleaf.org"
      th:replace="fragments/layout(title='能力评估',jsPaths='/static/js/assessment/assess.js,/static/plugins/jquery-migrate-1.2.1.min.js,/static/plugins/jquery.jqprint-0.3.js'
      ,cssPaths='/static/css/assessment/assess.css')">

<div class="right" th:fragment="right">
    <!--面包屑-->
    <div class="breadcrumb layui-bg-gray">
            <span class="layui-breadcrumb" lay-separator=">">
                <a th:href="@{/}">首页</a>
                <a href="javascript:void(0)">能力评估</a>
            </span>
    </div>

    <!--主体内容区-->
    <div class="form-content" id="print">
        <form class="layui-form" th:action="@{/gbassessRecords/submit}" method="post">
            <div class="layui-row">
                <div class="layui-col-md12 layui-col-lg10 layui-col-lg-offset1">
                    <div class="layui-form-item">
                        <label class="layui-form-label must">老人姓名</label>
                        <div class="layui-input-inline">
                            <input type="text" name="elderlyName" id="elderlyName" readonly required
                                   lay-verify="required" placeholder="请点击选择老人姓名" autocomplete="off" class="layui-input">
                            <input type="hidden" name="elderlyId" id="elderlyId">
                            <input type="hidden" name="elderlyIdNo" id="elderlyIdNo">
                        </div>

                        <label class="layui-form-label must">评估原因</label>
                        <div class="layui-input-inline">
                            <select name="cause" lay-verify="required">
                                <option value=""></option>
                                <option value="1">接收服务前初评</option>
                                <option value="2">接收服务后的常规评估</option>
                                <option value="3">状况发生变化后的即时评估</option>
                                <option value="4">因评估结果有疑问进行的复评</option>
                            </select>
                        </div>
                        <div class="layui-form-mid layui-word-aux hulve" style="margin-left: 40px;">
                            若未找到该老人档案，请先<a href="/enterElderly/add" style="color: blue;">创建老人档案</a>
                        </div>
                    </div>

                    <blockquote class="layui-elem-quote" style="font-size: 20px;">自主吃饭</blockquote>
                    <div style="padding:5px 20px;">
                            <div style="font-size: 20px;background-color: lightgoldenrodyellow;" > 使用餐具（包括筷子、勺子、叉子等）将食物送入口中、对碗筷（碟）的把持、完成咀嚼、吞咽等活动</div></br>
                                <input type="radio" name="selfEat" value="0"><span style="font-size: 17px;">可自主完成</span>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                                <input type="radio" name="selfEat" value="1"><span style="font-size: 17px;">不能自主完成</span>
                    </div>

                    <blockquote class="layui-elem-quote" style="font-size: 20px;">自主穿衣</blockquote>
                    <div style="padding:5px 20px;">
                        <div style="font-size: 20px;background-color: lightgoldenrodyellow;" > 穿脱衣服、系扣子、拉拉链、穿脱鞋袜、系鞋带等活动</div></br>
                        <input type="radio" name="selfGarb" value="0"><span style="font-size: 17px;">可自主完成</span>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                        <input type="radio" name="selfGarb" value="1"><span style="font-size: 17px;">不能自主完成</span>
                    </div>

                    <blockquote class="layui-elem-quote" style="font-size: 20px;">自主上下床</blockquote>
                    <div style="padding:5px 20px;">
                        <div style="font-size: 20px;background-color: lightgoldenrodyellow;" > 无需协助独立上下床等活动</div></br>
                        <input type="radio" name="selfGoBed" value="0"><span style="font-size: 17px;">可自主完成</span>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                        <input type="radio" name="selfGoBed"  value="1"><span style="font-size: 17px;">不能自主完成</span>
                    </div>

                    <blockquote class="layui-elem-quote" style="font-size: 20px;">自主如厕</blockquote>
                    <div style="padding:5px 20px;">
                        <div style="font-size: 20px;background-color: lightgoldenrodyellow;" >去厕所、解开衣裤、擦净、整理衣裤、冲水等活动</div></br>
                        <input type="radio" name="selfToilet" value="0"><span style="font-size: 17px;">可自主完成</span>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                        <input type="radio" name="selfToilet"  value="1"><span style="font-size: 17px;">不能自主完成</span>
                    </div>

                    <blockquote class="layui-elem-quote" style="font-size: 20px;">自主行走</blockquote>
                    <div style="padding:5px 20px;">
                        <div style="font-size: 20px;background-color: lightgoldenrodyellow;" > 站立、转移、行走、上下楼梯、户外活动等 </div></br>
                        <input type="radio" name="selfWalk" value="0"><span style="font-size: 17px;">可自主完成</span>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                        <input type="radio" name="selfWalk"  value="1"><span style="font-size: 17px;">不能自主完成</span>
                    </div>

                    <blockquote class="layui-elem-quote" style="font-size: 20px;">自主洗澡</blockquote>
                    <div style="padding:5px 20px;">
                        <div style="font-size: 20px;background-color: lightgoldenrodyellow;" >洗头、梳头、洗脸、刷牙、剃须、洗澡等活动</div></br>
                        <input type="radio" name="selfLave" value="0"><span style="font-size: 17px;">可自主完成</span>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                        <input type="radio" name="selfLave"  value="1"><span style="font-size: 17px;">不能自主完成</span>
                    </div>
                    </br>
                    <div class="layui-form-item hulve">
                        <div class="layui-input-block">
                            <button class="layui-btn layui-btn-normal" lay-submit lay-filter="formDemo">提 交</button>
                        </div>
                    </div>
                </div>
            </div>

        </form>
    </div>
</div>
</html>